1. Update 2010
	1.1 NOM in Children
	1.2 NOM in Adults
	1.3 Abdominal Ultrasound versus CT
	1.4 Angiography
2. Splenic Trauma in Africa
3. References
4. September 2005 Review

1. Update 2010

1.1. NOM in Children
Non-operative management of splenic injuries in children has become well established over the past two decades with many studies reporting ≥ 95% success rates. The evolution of current practice is well documented. (1) Moog in a review of 88 children managed for splenic injury reported only one case of operative intervention. (2) Hemodynamic stability remains a key requirement for NOM; while the position of NOM in cases with higher injury grades and the need for ICU requirement remain less resolved. These decisions should depend on the individual merits of each case. (3, 4) Splenic artery embolization (SAE) has enjoyed increasing acceptance in the past five years. (5) (See 1.4 Angiography)

1.2. NOM in Adults
The success of NOM in children encouraged the drive towards the same approach in adults even though the risk of OPSI is low in adult trauma patients. NOM has become the preferred approach in hemodynamically stable patients. (6, 7) However clinical evidence of ongoing blood loss or instability should be addressed with prompt surgical intervention. (6) Careful patient selection is of utmost importance in NOM. Predictors of success remain debatable. Bala studied 64 patients and found that admission systolic blood pressure and associated injury to less than 3 extra abdominal regions were predictors of success; while the need for blood transfusion was a strong predictor for splenectomy. (8) In a large retrospective review, age greater than 55 years, ISS higher than 25, along with admission to a level III or IV trauma hospital were associated with significant risk of failure of NOM.(9) While these issues remain unresolved, the success rates of NOM for splenic injuries have continued to improve, even in low-volume tropical countries. (9, 10) In a 15 year review of NOM, success rates moved from 77% to 96%. (11) The authors noted an increasing use of SAE to be contributory to improved success rates.

Failure of NOM is defined as need for surgical intervention after initially being selected for observation. This may be secondary to hemodynamic instability, peritonitis or persistent decline in hemoglobin after transfusion requirement ≥ 2 units of blood. (12) The optimum time for observation of blunt splenic patients in hospital has not been determined. Most patients who fail NOM do so within 48 hours. (12) Observation for 3-5 days would be an acceptable compromise.
There is no evidence based answer to the question of when an individual, who underwent successful NOM for splenic injury, should return to contact sports but many centres still favor the traditional 3 months.

1.3. Abdominal Ultrasound versus CT 

Abdominal CT scanning remains the gold standard diagnostic test if NOM is to be pursued. CT abdomen helps to delineate severity of organ injury and the presence of a vascular blush in the spleen is often taken to be sign of ongoing bleeding. It is also being used for the follow up of patients with splenic injury, but its role in this regard remains to be validated. The draw backs of CT include the need for patient stability and the potential for missed injuries to hollow viscera.
FAST has continued to be used for detection of hemoperitoneum in unstable patients. However there has been increasing interest in Contrast Enhanced Ultrasound Scan (CEUS). It provides a good alternative to multislice CT scan. (13) CEUS is available at the bedside, accurate for detection of solid organ injury, able to detect active bleeding while avoiding the risk of ionizing radiation. (14) A multicentre study has also shown the sensitivity of CEUS. (15)

1.4. Angiography

SAE has gained increasing focus in recent years with several studies showing that it improves success rates when incorporated into the NOM protocol. (16-19) There have also been studies showing SAE to have an unclear role in NOM. Habrecht found no difference in outcome when SAE was included or removed from the NOM protocol. (20) Also, in an 8 year review of NOM, Akpofure found no clear role for SAE. (21) Complications of SAE include total or partial splenic infarction, splenic atrophy, post procedure bleeding, and pleural effusion. For these reasons the need for caution has been stressed. (22)

2. Splenic Trauma in Africa

The management issues, highlighted in the 2005 Review concerning splenic trauma in Africa, are still present, but some changes have occurred in the past five years. At the University of Benin Teaching Hospital for instance a publication in 2001 (23) showed that all patients with splenic injury were subjected to surgery. Currently over 90% of pediatric blunt splenic injuries are managed using NOM in this institution. We recently published our initial experience of NOM in adult patients. (24) In that study we identified challenges encountered in the management of splenic injuries in Nigeria to include delayed presentation, under-utilization of CT, unavailability of interventional radiology, inadequate ICUs, limited vaccination, discharge against medical advice and poor follow-up. Despite these problems NOM is possible in Africa at least in the major trauma centres where the majority of severely injured patients are managed.

In our Trauma unit at the University of Benin Teaching Hospital, adult patients with blunt abdominal trauma, who are not hemodynamically compromised, are entered into the NOM Protocol.

1. A chart for hourly monitoring of pulse rate, blood pressure, respiratory rate, urinary output, GCS, and clinical reassessment of the abdomen if conscious is opened at the commencement of protocol. This is usually done by the trauma registrar and intern with intermittent reviews by the consultant trauma surgeon
2. Abdominal ultrasound scan is done on the first day in the ED and at least another one in 48 hours.
3. Initial CT scan of the abdomen where the patient can afford it.
4. Serial hematocrit determinations three times daily at 7am, 2pm and 10pm.
5. The patient monitoring is done in the Trauma bay or the Emergency ward which is attached to the Emergency Room under the management of the Trauma Unit.
6. The patient is X-matched for 3-4 units of blood in the blood bank and held.
7. Anesthetists review the patient on day 1 and remain on standby to take the patient for laparotomy should the need arise.
8. Similarly the Operating Room is kept aware of the case while NOM progresses.
9. If NOM is successful the patient is discharged on Day 5 with counseling on contact sports and the need to return promptly to hospital if there is any untoward development.
10. Both NOM and splenectomy patients are followed up for as long as possible but at least for 2 years.

The failures we have recorded followed hemodynamic instability, decreasing hematocrit or onset of peritonitis. The patients underwent prompt laparotomy for splenic salvage or splenectomy depending on operative findings.

Splenectomy patients receive vaccination against Pneumococcus, Haemophilus and Meningococcus, but oftentimes we have challenges here and not all the patients eventually get these vaccines prior to discharge. But we have not had any case of OPSI in all the ones that kept follow-up schedule.
What are the facts on blunt splenic injuries in Africa?

1. Majority still result from road traffic accidents.
2. Most surgeons working outside University Teaching Hospital Centres still treat splenic injuries by operative intervention and usually splenectomy.
3. Materials for splenorrhaphy such as fibrin glue or Dexon mesh are unavailable, but Surgicel is available in many centres. Partial splenectomy is very uncommon as a result.
4. NOM has become established in children and is gaining popularity in adults.
5. Interventional radiology as a specialty is unavailable in sub-Saharan Africa and so SAE as part of NOM is absent.
6. Most hospitals that treat trauma can meet monitoring needs, if there is a knowledgeable and dedicated in-house surgeon to direct protocol and management.
7. CT has become available in all teaching hospitals and in many secondary and private facilities, but there is an affordability crisis. Patients cannot afford to pay for the services and so CT is under-utilized in blunt abdominal trauma.
8. DPL is unpopular here, but ultrasound facilities and personnel are in abundance in most parts of Africa.
9. Professional trauma and acute care surgeons are in short supply and indeed the specialty is still in the teething stage, with much suspicion and challenge from other surgical specialties, but general surgeons abound.
10. One recommendation that was made in the original review is that techniques of splenorrhaphy be taught in African surgical training programmes. This procedure has always been and is still being taught. The reason limiting its applicability is explained above.

In conclusion there are remarkable changes in the approach to management of blunt splenic injury in Africa. The role of NOM is increasingly being recognized, but local limitations make the wide scale application lag behind the pace of the developed world.

Dr. Pius Iribhogbe
Consultant Trauma and General Surgeon
Director of Trauma and Emergency Services
University of Benin Teaching Hospital
Benin City, Nigeria

3. References

1. Thompson SR, Holland AJ. Evolution of non-operative management for blunt splenic trauma in children. J Paediatr Child Health 2006 42:231-234 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109135

2. Moog R, Mefat L, Kauffmann I, Becmeur F. Non operative management of splenic trauma. Arch Pediatr 2005 12: 219-223 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109136

3. Notash AY, Amoli HA, Nikandish A, Kenari AY, Jahangiri F, Khashaya P. Non operative management in blunt splenic trauma. Emerg Med J 2008 25: 210-212 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109137

4. Thompson SR, Holland AJ. Current management of blunt splenic trauma in children. ANZ J Surg 2006 76: 48-52 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109138

5. Kiankhooy A, Sartorelli KH, Vane DW, Bhave AD. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma 2010 68: 526-531 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109139

6. Forsythe RM, Harbrecht BG, Peitzman AB. Blunt splenic trauma. Scandinavian Journal of Surgery 2006 95: 146-151

7. Galvan DA, Peitzman AB. Failure of nonoperative management of abdominal solid organ injuries. Curr Opin Crit Care 2006 12: 590-594 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109140

8. Bala M, Edden Y, Mintz Y, Kisselgoff D, Gercenstein I, Rivkind AI, Farugy M, Almogy G. Blunt splenic trauma: predictors for successful non-operative management. Israel Medical Association Journal: imaj 2007 9: 857-861

9. McIntyre LK, Schiff M, Jurkovich GJ. Failure of non-operative management of splenic injuries: causes and consequences. Archives of surgery 2005 140: 563-568 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109141
10. Kuzma J, Atua V. Conservative management of splenic injury in the tropics. Tropical Doctor 2008 38: 210-213 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109142

11. Rajani RR, Claridge JA, Yowler CJ, Patrick P, Wiant A Summers JI, McDonald AA, Como JJ, Malangoni MA. Improved outcome of adult blunt splenic injury: a cohort analysis. Surgery 2006 140: 625-631 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109143

12. McCray VW, Davis JW, Lemaster D, Parks SN. Observation for nonoperative management of the spleen: How long is long enough? T Trauma 2008 65: 1354-1358 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109144

13. Clevert DA, Weckbach S, Minaifar N, Clevert DA, Stickel M, Reiser M. Contrast-enhanced ultrasound versus MS-CT in blunt abdominal trauma. Clin Hemorheol Microcirc 2008 39: 155-169 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109145

14. Valentino M, Ansaloni L, Catena F, Pavlica P, Pinna AD, Barozzi L. Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years experience. Radiol Med 2009 114: 1080-1093 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109146

15. Catalano O, Ajani L, Barozzi L, Bokor D, De Marchi A, Faletti C, Maggioni F, Montanari N, Orlandi PE, Siani A, Sidhu PS, Thompson PK, Valentino M, Ziosi A, Martegani A. CEUS in abdominal trauma: multi-center study. Abdom imaging 2009 34: 225-234 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109147

16. Benjamin W, Mark RH, Sarman A, Paul AT, Wendy L. Angioembolization reduces operative intervention for blunt splenic injury. J Trauma 2008 64: 1472-1477

17. Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. J Trauma 2009 67: 565-572 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109148

18. Ekeh AP, McCarthy MC, Woods RJ, Haley E. Complications arising from splenic embolization after blunt splenic trauma. Am J Surg 2005 189: 335-339 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109149

19. Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma 2005 58: 492-498 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109150

20. Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman AB. Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma 2007 63: 44-49 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109151

21. Ekeh AP, Izu B, Ryan M, McCarthy MC. The impact of splenic artery embolization on the management of splenic trauma: an 8-year review. Am J Surg 2009 197: 337-341 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109152

22. Wu SC, Chen RJ, Yang AD, Tung CC, Lee KH. Complications associated with embolization in the treatment of blunt splenic injury. World Journal of Surgery 2008 32: 476-48         http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/109153

23. Ohanaka EC, Osime U, Okonkwo CE. A five year review of splenic injuries in the University of Benin Teaching Hospital, Benin City, Nigeria. West Afr. J.Med 2001 Jan-Mar 20(1): 48-51.

24. Iribhogbe PE, Okolo CJ. Management of splenic injuries in a University Teaching Hospital in Nigeria. West African Journal of Medicine 2009 28: 308-312